B. Tucker Woodson, MD, is Professor and Chief of the Division of Sleep Medicine, Department of Otolaryngology and Communication Services at the Medical College of Wisconsin in Milwaukee.
Many non-otolaryngologists, and even some otolaryngologists, ask: Why would surgeons-especially busy ones-care about sleep medicine? Do they really want to read sleep studies? Is the link tying otolaryngology to sleep medicine broad enough to make it important to more than a handful of individuals? I argue that sleep medicine is not a novelty but rather an integral part of otolaryngology. The otolaryngologist should not be relegated to a consultant to be called on as needed; he or she must be an active member of the sleep medicine community, for several reasons.
The field of sleep medicine is inherently heterogeneous. No specialty corners the market on sleep. Sleep medicine specialists come from divergent backgrounds with great strengths in some areas of sleep and a total unfamiliarity with others. Our specialty has the greatest expertise in the disorder that has the greatest impact in the specialty (i.e., sleep-disordered breathing). Each primary specialty brings to sleep medicine unique expertise and patient populations. The sleep disorder patients of pediatricians are incomparable to those of the adult neurologist treating Parkinson’s disease patients. Despite the varying breadth of sleep medicine practices, training and examinations in sleep must be uniform.
Otolaryngologists are surgeons. The ability to perform surgery and other therapeutic interventions augments the diagnostic and medical therapeutics in sleep. Not only is being a surgeon a poor argument to not enter the sleep field, but it is an exciting opportunity for sleep medicine to attract some of the best and brightest trainees who come from our specialty. Surgeons who pursue added qualifications in this field will endow sleep medicine with a unique perspective. These renaissance sleep surgeons will enlighten both sleep medicine and otolaryngology.
Many otolaryngologists have a large percentage of sleep medicine in their practices, albeit highly focused on breathing disorders. A narrow focus of practice does not mean that a broader knowledge of sleep is not needed. Few individuals who present for surgery have only one sleep disorder. A broader emphasis on sleep and sleep disorders different from apnea can be added into current practices and are not beyond our level of expertise. Otolaryngologists already have practices that serve many divergent populations and disorders (i.e., medical, surgical, geriatric, adult, pediatric). We treat multiple medical disorders as complex as sleep disorders including medical otology, allergy, headaches, and reflux disease. Additional, knowledge in sleep will allow many to expand clinical practice and improve patient care.
Value of Certification in Sleep Medicine
Compared with the medical specialists who are or will be certified in sleep, otolaryngologists will be a distinctive group. Not only will their numbers be smaller, but those otolaryngologists more motivated to seek such certification will be unique. Within the sleep community, the sleep-trained otolaryngologist will have skills and knowledge that no other group within the specialty can acquire. As such, certification in sleep medicine provides major growth opportunities for otolaryngology in academic, public health, research and other health care arenas.
Prior to the new board certification process, a historical bias obstructed access to the field compared with other medical specialties. The opportunity to participate in the sleep lab or to be eligible to take the previous sleep medicine exam was difficult. Despite the personal and professional efforts that were often needed, I have not met one otolaryngologist who regrets pursuing sleep medicine. Uniformly, their only regret is not doing more sleep medicine earlier. The new certification process has welcomed otolaryngologists with open arms.
For some, sleep medicine is defined by the polysomnogram. If true, the future discovery of a blood test for sleep apnea will be sleep medicine’s Armageddon (or end of the sleep medicine world as we know it). However, for those who view the field of sleep medicine not as a test but as a wide variety of clinical competencies, scoring or reading sleep studies does not define the field.
Historically the sleep lab was the center and engine driving the sleep universe, but as the engine that drove the field, it has also been its anchor. Maturity of the field will likely alter the role and ways polysomnography is performed. Otolaryngology should be a part of this change. In the future, running a sleep lab as we know it may not be a major part of sleep medicine. Entire evolving technologies will likely fill the gap.
The goal of subcertification in sleep is to improve patient care and outcomes. Comprehensive knowledge of sleep matters. Even surgeons who only do airway surgery must have a responsibility to ensure that all diagnostic evaluation is performed and appropriate therapies prescribed. To restrict otolaryngology’s participation to that which can be reached by the scalpel is as ludicrous as limiting the scope of knowledge and qualifications of the neurotologist to those disorders that can be reached by the drill.
Plan of Action
To reach this end, what are otolaryngologists to do? I recommend several possible strategies. These may include pairing up with local sleep physicians or attending national or international courses devoted exclusively to sleep issues.
Learn from your patients. This begins with taking a sleep history. Few patients have only one sleep disorder, and the more comprehensive approach will be educational and will result in improved patient care.
Join the American Academy of Sleep Medicine. Establish contacts with those who are already actively involved in otolaryngology and sleep, who will be enthusiastic to share expertise and experiences.
Finally, do not let structural or political impediments prevent you from pursuing an interest in sleep. Years ago, sleep studies involved a ceiling-high array of amplifiers, a maze of ink pens, and an entire forest turned into paper. It was the private and exclusive domain of the clinical polysomnographer. Sleep studies are now far more accessible. They can be only a mouse click away or carried on a CD. The needed equipment may be with an amplifier smaller than one’s hand.
Ultimately, board subcertification in sleep medicine is an enormous opportunity for otolaryngology and improved patient care and outcomes. I encourage those with an interest in sleep to actively participate in the future academic, educational, and socioeconomic growth of sleep medicine.
©2007 The Triological Society